Clinical Teaching for LGBT Health at the Point of Care

28 Jun 2016

by Sarah E. Stumbar, MD, MPH

“Do you live with your husband, too?” the second-year medical student asked, innocently enough. It was our first visit with this patient, a healthy middle-aged African American woman. We were just chatting, trying to get to know her, and I had picked up on little clues in our conversation that had already led me to conclude that there was no husband in the picture. The medical student, though, didn’t seem to have picked up on this and, I thought, was trying to get at her sexual history by asking, instead, about her husband.

A few seconds of an awkward, heavy silence followed his question, until the patient forcefully said, “I’m an independent woman.” There was no room left open in her tone for further discussion, and our conversation quickly moved onto other topics.

Later, after the visit, I challenged the medical student to go back to that question and think of all of its assumptions: a heterosexual relationship, the need for a husband to have a child, the assumption that asking about a husband equated to asking a sexual history. I could see the student processing all of this, as he squinted his eyes and stated, “I come from a very conservative family.”

We discussed how we all bring our own histories to our patient interactions but also how these histories cannot come with judgments that impact our patient care. I pointed out how his question had been a dead-end and that we had learned nothing about the patient’s sexual practices or sexuality or romantic relationships. We talked about how he might ask the same question differently next time. I could tell that our conversation pushed the medical student outside of his comfort zone but that these few minutes of clinical teaching had started to show him the judgment that our patients implicitly feel when our questions make assumptions. We want to open conversations, not close them.

Driving home that night, I thought about my own formative experience learning about assumptions during medical school. During my fourth year, I did a 2-week elective at Callen-Lorde Community Health Center, a federally qualified health center that treats primarily an LGBT population in New York City. Unlike my medical student, I grew up in a community with people who identified all across (and outside of) the traditional spectrum of genders and sexualities. I had sought out this experience as a way to learn more about LGBT-specific health issues, such as hormone therapy.

On one of my first days, the attending physician instructed me to do a testicular exam on our patient, a well-coiffed woman wearing skinny jeans and a tube-top. I remember willing my face not to show my surprise at my attending’s instructions; it had not occurred to me that this attractive young woman had testicles or a penis. I went home that night realizing the limitations of what I knew, particularly when identities and realities converge and contradict each other within a patient’s body.

When teaching medical students about LGBT health, I hope to convey to them that this means more than just assessing sexual practices and risk behaviors. Rather, understanding LGBT health—and, in fact, the health of everyone—means embracing the central roles that sexuality and gender-identities play in our patients’ lives. It is our job to learn how to turn our exam rooms into a place where gender and sexuality can openly unfold in all of their contradictions and complexities.

For our students, in the clinic, this means that it’s our job to constantly teach and model patient interactions that challenge the preconceived assumptions that we all have. This means that we ask questions that are open for a patient’s interpretations, devoid of gendered pronouns and heterosexual assumptions. This means that when we are unsure of how patients identify, we are able to ask them in a way that is respectful and embracing of all the possibilities. This means that we never let an opportunity to teach at the point of care pass us by; we work to show and challenge our students’ biases and assumptions (and our own).

For our students, in the classroom, teaching about gender and sexuality means that we advocate for a curriculum that longitudinally and progressively integrates LGBT health and identities. It means rejecting a curriculum that compartmentalizes LGBT health into a 1-hour lecture where a token “trans-person” is invited to speak. It means a curriculum that recognizes LGBT health as more than just an evaluation of risk factors. It means creating a medical culture—in the classroom and in the clinic—that moves beyond normalized and narrow heterosexual binaries.